title: Spontaneous rupture of hepatocellular carcinoma: a Western experience.
abstract: BACKGROUND
  Spontaneous rupture of hepatocellular carcinoma (HCC) is a life-threatening presentation, with an incidence of <3% of HCC patients in Western countries. The reported overall mortality is < or =50% in Asian countries, where the incidence is 12% to 14%. The aim of this study was to report a single center's experience of patients with ruptured HCC during a 11-year period.
  
  
  METHODS
  A retrospective review was performed of all patients who presented with ruptured HCC between 1995 and 2005. Data on clinical features, treatment strategies, and survival outcomes were collected. Statistical methods included univariate analysis and Kaplan-Meier survival estimates with log-rank test.
  
  
  RESULTS
  A cohort of 21 patients (15 male and 6 female) was identified. Fourteen (66.6%) patients had histologic evidence of underlying cirrhosis, ad the median age at presentation was 68 years (interquartile range [IQR] 61 to 69). Ten of these patients (71.4%) were hemodynamically unstable at presentation. The mean tumor size was 8.5 cm (range 3 to 13), and there was multifocal disease in 6 (42.8%) patients. The etiology of cirrhosis was hepatitis B infection in 3, hepatitis C in 3, alcohol in 4, and cryptogenic in 4 patients. Initial bleeding control was attempted by transarterial embolization (TAE) in 7 (50%) and by emergency surgery in 7 patients (50%). Four of the operations were performed at referring hospitals, and 3 were performed at our institution. Two patients (14.2%) underwent palliative treatment only. Definitive treatment included resection at emergency surgery in 1, staged hepatectomy in 1, and transarterial chemoembolization in 2 patients. There were 7 patients who were noncirrhotic and had a median age of 51 years (IQR 42 to 60). Of these, 6 (87.5%) were hemodynamically unstable at presentation. Mean tumor size was 9 cm (range 6 to 18) and confined to right lobe in all patients. Primary hemostasis was successfully achieved by TAE in 2 and perihepatic packing in 1 patient. Definitive treatment was provided by emergency hepatectomy in 4 and staged hepatectomy in 3 patients. Patients with cirrhosis (n = 14) had a median survival rate of <30 days. Child-Pugh score at presentation (median 7, IQR 5 to 8) correlated strongly with overall survival (P <.0001). Median survival for noncirrhotic patients was 20 months (IQR 2 to 31). One patient without cirrhosis survived for 122 months without disease recurrence.
  
  
  CONCLUSIONS
  Spontaneous rupture of HCC is an uncommon presentation in Western countries. Primary hemostasis, followed by emergency or staged hepatic resection, is the treatment of choice. Median survival in patients initially treated with surgery was better than that observed in patients who underwent initial TAE, although this was not statistically significant. Patients who had no underlying liver disease had better prognosis than those who had cirrhosis.
authors.affiliation: Institute of Liver Studies, King's College London School of Medicine, King's College Hospital, Denmark Hill, Camberwell, London, UK.
authors.forename: Narendra
authors.initials: N
authors.lastname: Battula
authors.forename: Mansoor
authors.initials: M
authors.lastname: Madanur
authors.forename: Oliver
authors.initials: O
authors.lastname: Priest
authors.forename: Parthi
authors.initials: P
authors.lastname: Srinivasan
authors.forename: John
authors.initials: J
authors.lastname: O'Grady
authors.forename: Michael A
authors.initials: MA
authors.lastname: Heneghan
authors.forename: Matthew
authors.initials: M
authors.lastname: Bowles
authors.forename: Paolo
authors.initials: P
authors.lastname: Muiesan
authors.forename: Nigel
authors.initials: N
authors.lastname: Heaton
authors.forename: Mohamed
authors.initials: M
authors.lastname: Rela
mesh_terms: D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000150:complications* / Q000601:surgery; D005260:Female; D006470:Hemorrhage / Q000209:etiology* / Q000628:therapy; D006498:Hepatectomy; D006801:Humans; D008113:Liver Neoplasms / Q000150:complications* / Q000601:surgery; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012422:Rupture, Spontaneous